Comparative Effectiveness of Manual Therapy Interventions on Pain and Pressure Pain Threshold in Patients With Myofascial Trigger Points

Abstract

Objectives: Myofascial trigger points (MTPs) are one of the most important causes of musculoskeletal pain. Evidence has suggested a positive effect of manual therapy in the treatment of MTPs. However, a comprehensive review comparing the effect of different manual therapy techniques are lacking. Thus, we conducted a network meta-analysis of randomized controlled trials to determine the type of manual therapy technique that has the greatest positive influence in patients with MTPs.Materials and Methods: PubMed, Web of Science, Cochrane Library, and Scopus databases were searched to identify direct and indirect evidence comparing the effectiveness of different types of manual therapy interventions on pain intensity and pressure pain threshold (PPT) in patients with MTPs. Risk of bias was assessed using the Cochrane RoB2 tool. A pairwise meta-analysis for direct and indirect comparisons between intervention and control/nonintervention groups was carried out.Results: A total of 37 studies were eligible for analysis. Combined interventions had the highest effect size for pain (−1.40; 95% CI, −2.34, −0.47), and the highest probability to be the best intervention and the highest Surface Under the Cumulative Ranking (64.7% and 87.9%, respectively). Afferent reduction techniques, understood as the interventions aimed to restore muscle spindles helping to dictate sarcomere length and tone in MTPs, had the highest effect size for PPT (0.93; 95% CI, 0.47, 1.39), and the highest probability to be the best intervention and the highest Surface Under the Cumulative Ranking (34.7% and 71.2%, respectively). The results were consistent in sensitivity analyses, with minimal inconsistencies between direct and indirect results.Discussion: Manual therapy interventions should be considered an effective strategy for pain and PPT in patients with MTPs. The results suggest that among the different manual therapy modalities, combined and afferent reduction techniques are the most effective for pain and PPT, respectively.

Restoration of normal central pain processing following manual therapy in nonspecific chronic neck pain

“…Significant attenuation of TSP was found here following manual therapy, an observation in keeping with previous reports using this therapeutic modality both in healthy volunteers [ 56 ] and pain conditions such as low back pain [ 57 ] and carpal tunnel syndrome [ 58 ]. It is noteworthy, however, that studies conducted so far specifically in patients with NSCNP have failed to report changes in TSP following a variety of interventions other than manual therapy, including virtual reality [ 22 ], cervical therapeutic exercise [ 22 , 59 ] and a combined protocol of electrotherapy and cervical therapeutic exercise [ 15 ]. This raises an interesting question as to the ability of different therapy modalities to influence TSP, a scenario where manual therapy has proven to exert a significant attenuating effect as shown here and may therefore be best indicated in patients with a pronounced pronociceptive profile at baseline.…”

“…Although changes in central pain processing have been reported following manual therapy (Mulligan’s mobilization with movement, cervical manipulation, anteroposterior mobilisations, lateral glide mobilization, Maitlands passive accesory mobilization, etc. ), most studies have relied on static psychophysical measures (largely assessment of pressure pain thresholds) and found amelioration of local [ 12 , 15 , 16 ] and in some cases distal hyperalgesia [ 17 ]. However, studies assessing the effects of manual therapy using dynamic psychophysical tests are scarce, and relatively little is known on the effects of manual therapy on central pain processing mechanisms.…”

Myofascial Pain Syndrome: A Nociceptive Condition Comorbid with Neuropathic or Nociplastic Pain

“…From a clinical viewpoint, in patients with the nociceptive phenotype, functional activity and early treatments that target the peripheral noxious input can be effectively used. This hypothesis is supported by meta-analyses reporting that manual therapies [ 39 ] and exercise programs [ 40 ] are effective strategies for decreasing pain and sensitivity in patients with TrPs.…”

“…Current management approaches for TrP pain are mainly focused on peripheral strategies targeted to inactivate the TrP [ 87 ]. Meta-analyses support the use of manual therapies [ 39 ] and dry needling [ 88 ] for decreasing pain and sensitivity in the short term in people with TrP pain. However, evidence shows that the effects of these interventions have mostly short- or moderate-term benefit but minimal long-term benefit [ 39 , 88 ].…”

“…Meta-analyses support the use of manual therapies [ 39 ] and dry needling [ 88 ] for decreasing pain and sensitivity in the short term in people with TrP pain. However, evidence shows that the effects of these interventions have mostly short- or moderate-term benefit but minimal long-term benefit [ 39 , 88 ]. A potential explanation of the lack of long-term benefit following local TrP treatment could be related to the lack of identification of those individuals with a nociplastic phenotype requiring a more extensive or holistic treatment approach.…”